I HATE contingency orders

[Melanin]

This one was a heparin drip, and I misread the order, which said that if the factor Xa is above ___, turn off the heparin for 60 minutes and then restart the heparin but decrease the dose by 300 units/hour. Well, I for some reason I read the order as "turn off the heparin for 3 hours and then restart the heparin but decrease the dose by 300 units." So at 1400 I turned off the heparin, then at 1500 I told the oncoming RN that the heparin should be restarted at 1700 & decreased by 300. The evening RN asked if there were written orders for her to check, and I said that yes, the MD orders were there to read, in case she wanted to double check what I'd reported (that's certainly what I would do). At 1530, after finishing all my reports and charting, I clocked out. At 1600, while I'm on the train home, I get a call on my cell from the previous RN asking where I got the "3 hours" stuff. I did not have access to my work computer at that point, so I said that I THOUGHT the order had read "turn off for 3 hours" - had I misread it? The previous RN just shouted, "WRONG," then said she'd restart the heparin now.

I guess my question is, how much trouble am I in? I'm pretty sure the evening RN will report me, write an incident report, etc because she sounded pretty indignant on the phone. Sometimes I hate being a nurse, but I try and I try and I try to do everything perfectly.

[Sour Lemon]

The patient wasn't harmed, presumedly. Hopefully your coworkers and boss will look at it as a learning experience. For high risk "things" like heparin drips, it's often useful to have a nurse buddy look things over and make sure all is well ...especially when you're busy and flustered.

[Been there,done that, ASN, RN]

Most facilities require a witness when adjusting Heparin. You misread the order. Most heparin standing orders are.. hold the drip for an hour.. and go from there. Do you know the half -life of Heparin?

Most likely there was no patient harm.. but you made a big med error. Now you know to triple check anything to do with a Heparin drip.

[cleback]

Honestly, for something as potentially harmful as heparin, I would not want contingency orders either. Is that best practice? Maybe its something your nursing practice council can look at. I doubt you re the first person to make a mistake on that. If your unit is non punitive, report yourself. Maybe they'll do a RCA and change the orders.

[Melanin]

Nobody was harmed (thought the potential was there). I made an error that the next nurse caught for me an hour too late, which could be a good learning experience, except that it sucks to have to learn this way. My facility is very punitive, so I figure there'll be consequences. I won't get into the reasons, but it would be more than bad if I were fired or something (not that I'm special in this regard). Contingency orders really bug me! I think they're par for the course for heparin, which, if I had more experience with heparin drips, I would have realized is something that you typically hold for one hour. But I didn't. And yeah, I was busy and flustered and the relief was too busy to help me today. Which is not an excuse, I know. But I wish this profession allowed us to be human beings & not perfect robots. Stuff like this makes me think I need to figure out if there's some kind of nursing thing I can do that isn't so risky. Yeah, I know we get paid pretty well, but I'm not sure if it's worth it. You know what I mean?

[MunoRN, RN]

Mistakes are how we learn, what you'll learn from this is that due to the short half-life of IV heparin, it would be unusual to have a 3 hour pause to adjust the ptt, now you know.

I don't think there is a viable alternative however to these types of orders, how should it work instead?

[Melanin]

That's a very good question. I wonder if we could have a certain allotted time in the am to examine all the contingency orders and get the straight, rather than being expected to pick them up on the fly. That is, I don't regularly have enough time during my shift to examine all the orders because as soon as I clock in, I have to RUN to keep up with the antibiotics and assists to the commode and pain med requests and bad IVs and CT consents, etc. Also, we have to hunt for contingency orders, which could be on the active orders page, or written in small print on the PRN mar, or else written in on the scheduled medication MAR. Hunting for parameters can be rough when you're dealing with an unfamiliar medication, or with an MD with their own preferences (some say transfuse for hemoglobin

[MurseJJ]

That's a very good question. I wonder if we could have a certain allotted time in the am to examine all the contingency orders and get the straight, rather than being expected to pick them up on the fly. That is, I don't regularly have enough time during my shift to examine all the orders because as soon as I clock in, I have to RUN to keep up with the antibiotics and assists to the commode and pain med requests and bad IVs and CT consents, etc. Also, we have to hunt for contingency orders, which could be on the active orders page, or written in small print on the PRN mar, or else written in on the scheduled medication MAR. Hunting for parameters can be rough when you're dealing with an unfamiliar medication, or with an MD with their own preferences (some say transfuse for hemoglobin

I think the problem is that there isn't enough time to review the orders at the beginning of your shift, as you acknowledge. That doesn't sound like an ideal situation. Typically, at the start of your shift, you should be reviewing all of the orders during/after getting report from the off-going RN (at my hospital we do a 12 hour check), since it is now your responsibility to fulfill them (or question them if they are not indicated). If your assignment is already made prior to the start of your shift, it may be helpful to review the orders prior to getting report if possible. Also, as someone mentioned, with high alert medications, you should definitely review any changes in the treatment with another RN, whether or not it's hospital policy.

Hope that helps!

[Melanin]

True! One barrier I run into is that we're expected to start the shift by taking report at 0700 so that the night shift can leave by 0730 - which seems like plenty of time, but there's a lot going on sometimes. . . From 0730-0800 we start passing the 0800 meds, and around that time the lab results from the night shift start rolling in & we check the vitals entered by the CNAs and fill out all of the sepsis reports and look at all the blood sugar results. So if anyone wants a PRN or has to go to the bathroom or has low blood sugar or has an am procedure & we have to help with the transfer, our time is pretty squeezed (though yes, when there's a high-alert medication we should MAKE time). I've made a habit of showing up prior to my shift to review the orders before I clock in (since, as I said, we're not allowed to punch in/out late or early). However, a few of the night RNs have expressed anger that I am taking up space at a computer at the nursing station ("you're sitting at MY computer," is what they say), and more than one has warned me that I could be reported for a HIPPA violation, so I'm wondering if this is an unsafe approach (for me personally, not for the patient).

[JadedCPN, BSN, RN]

It sounds like your underlying issue here is time management. You absolutely have to make time to review all of your orders prior to starting patient care. If this isn't done during actual report like the previous poster mentioned a 12 hour chart check, then you need to take it upon yourself to make the time for it. I know some nurses who come in 15 minutes prior to being able to clock in for their shift to review their assignment's Orders just because they know time management is an issue for them. Whatever habit/whatever you need to do to make it happen, do it for both your patient's safety as well as the safety of your license.

[ladedah1, BSN, RN]

This makes me so grateful for the process used at my place of work.

Pharmacy manages heparin drips entirely. They get the lab results, interpret them, then call us to say – "Hey, stop the heparin for an hour and restart at (insert rate) at (insert time). They change it in the MAR... I go into the room and shut it off... an hour later – when it becomes due – start up requires a double check with another RN... and VIOLA, all done! Minimum risk of misreading the order!

I am surprised that your protocols don't call for a more involved process when it comes to something as important as a heparin drip...

Either way, I'm sorry this happened to you. Your place of employment should take steps to minimize catastrophes such as this. Not every scenario allows for the appropriate amount of time to read and interpret orders... and while we are technically responsible for this type of mistake... there are also many ways in which we are set up to make them...

[Melanin]

That sounds like a great system! It would help so much!